1 Introduction To Quality in Health Care Sesm.3-2016 1
2 How is quality assured? “It is the duty of each health care body to put and keep in place arrangements for the purpose of monitoring and improving the quality of health care provided by and for that body.” 2
3 What is quality assurance? Process of measuring quality, analysing the deficiencies discovered and taking action to improve performance, followed by measuring quality again to determine whether improvement has taken place. A systematic process for closing the gap between actual performance and desirable outcomes. 3
4 Defining quality in health care 4
5 Quality can be defined in various ways Quality is getting the best results possible within the available resources. Quality is the level of attainment of health systems’ intrinsic goals for health improvement and responsiveness to legitimate expectations of the population (World Health Organization). 5
6 In other words Quality is the extent to which health services provided to individuals and patient populations improve desired health outcomes. The care should be based on the strongest clinical evidence and provided in a technically and culturally competent manner with good communication and shared decision making. 6
7 Why does quality matter ? 7
8 Better for patient Good health outcome Client satisfaction Value for money Less frustrating 8
9 Better for health care providers 9
10 Better for the institution Patients more satisfied with services More patients will use the service The environment will improve Facility will have a good reputation 10
11 And - poor quality of care costs money Costs of wrong diagnosis and wrong treatment - repeated visits to clinic, prolonged illness, death Wasted time to patient and health worker Patients do not comply to treatment Unnecessary laboratory tests and reagents Low staff morale – absenteeism etc. Studies show that additional hospitalization, litigation costs, infections acquired in hospitals, lost income, disability and medical expenses have cost some countries between US$ 6 billion and US$ 29 billion a year. 11
12 Access to services. No financial, geographical, social, cultural, organisational or linguistic barriers Effectiveness. Intervention lead to the desired result. Evidence Technical competence Safe. Minimal risk of injury and infection Efficient. Product and service affordability. Maximise resources and minimise waste? Equitable. Delivering health care which does not vary in quality because of personal characteristics such as gender, race, ethnicity, geographical location, or socioeconomic status; Patient centred. Responsive to patient needs and acceptable Relevant. Is the overall pattern and balance of services the best hat can be achieved with the needs of the populations? Dimensions of quality - Maxwell 12
13 What do health care managers want ? Provide for needs of the health care providers and patients. Equity, access and effectiveness Efficient use of funds Appropriate use of resources Accountable to politically set goals and targets 13
14 What do health care providers want He / she has the skills, resources and conditions necessary to improve the health status of the patient Technical competence, effectiveness and safety Degree to which health care meets the current technical state of the art Freedom to act in the full interest of the patient Accountable to professional standards Safe and clean workplace 14
15 QUALITY ASSURANCE IN HEALTH CARE CHAPTER.2 15
16 Contents :Quality in Health Care Delivery Quality in Health Care Sector-Key Principles Infrastructure for Quality Assurance in Health Care Decision Making in Health Care Improvement Audit –Key Tool in Q.A 16
17 Quality in Health Care Sector : Key Principles 17
18 HEALTH CARE The system that a Nation has built up and continuously maintains in order to combat (unnecessary) Death,Disease,Disability,Dissatisfaction and (social) Disruption A collection of curative,preventive,rehabilitative and promotive services Health care is a social and economical endeavor encompassing activities by providers,consumers,financiers and government within their respective value systems 18
19 What’s wrong in today’s Health Care? Avoidable errors Underutilization of services Overuse of services Variation in services Communication problems Lack of Evidence Dissatisfied clients 19
20 What can we do about it? Do nothing Better education and training Policing,Inspection,Punishment Change,Improve,Reward Comprehensive Approach:Quality Assurance 20
21 Definition of Quality Why define quality of care? Reach consensus among employees Avoid confusion and in-house fighting Allow for sound evaluation Allow consumers to make a choice 21
22 From the beginning there was chaos quality assessment quality assurance quality improvement continuous quality improvement Information technology values 22
23 Quality :Terminology Quality Assurance: the overall philosophy on Quality and its Assurance Total Quality Management:one of the newest organizational and managerial approaches to Quality Assurance in the (not) for profit industry Continuous Quality Improvement:an important organizational and managerial mechanism for quality assurance in the health sector 23
24 Quality Improvement Important elements: External and internal customer satisfaction Management leadership Involves all personnel Uses statistical methods Focuses on improvements 24
25 Definition of healthcare quality Quality is working according to specifications Quality is providing effective services with a minimum of unnecessary use of resources Quality is to satisfy customers 25
26 The Core Principles The essentials are: Assuring(I.e assessing and improving) quality is the responsibility of the provider Quality assurance is an evaluation and improvement process Of all the necessary attributes(knowledge,skills,attitudes,values) values and attitudes are the most important 26
27 TOTAL QUALITY The end point of a development in phases: Focus on professional quality Focus on client satisfaction Focus on system effectiveness Focus on interconnections Organizational and societal unification 27
28 Why improve my quality Because I know it is needed because I am told to do so because I must survive Because I need to follow the rules Today’s choice:SURVIVAL 28
29 Mission Statement Rationale:programme Rationale:programme SURVIVAL My programme is dedicated to Provide high-quality service to the members of the community Employ well-trained professionals Maintain a high safety record Provide a customer –friendly environment 29
30 Plan high –quality services Identify priorities,goals and customers Set up working groups Describe service according to: -consumer and client needs - structure,process,outcome Make plans for evaluation 30
31 Quality Planning Establish Quality project: goals and team Identify customers Determine client needs Design services to be provided Design delivery process Determine information need Use and evaluate 31
32 Train professionals Select key professionals Design appropriate training Organize continuous training sessions Evaluate results of training including satisfaction Reward participants Repeat training regularly 32
33 Evaluation Includes assessment and improvement Orientation :what are the possibilities? Selection:What is most appropriate? Implement: who is doing what? Collect and discuss the results Disseminate the results inside and outside Prepare for the next round 33
34 Improvement of care Focus:Structure,Process and Outcome Structure:better equipment Process:doing the right things better! Outcome:obtain better results in - effective services -costs - client and employee satisfaction 34
35 Improvement of structure Includes building,equipment,personnel,manuals, information systems,rules and regulations Includes new provisions,and updating and refurbishing of old provisions Need to include recording of inputs and costs 35
36 Improvement of Process Principle:Doing the right things better! Doing the right things more effective! Doing the right things more efficient! Includes: Appropriate use of technology Appropriate use of personnel Client/provider relationship 36
37 Improvement of outcome Focus: Programme effectiveness Programme efficiency Consumer and employee satisfaction Consumer and employee education Building and technology safety Community relations Information and communication needs 37
38 Tools for Improvement Motivation Insight Evaluation methods Communication tools Dedicated personnel Dedicated Management Money 38
39 That implies: Quality improvement is essential for survival Customer satisfaction is important for survival Monetary support will come only after well- executed quality assurance studies 39
40 Infrastructure for Quality Assurance in Health Care 40
41 Quality Assurance Universe – Big including small Small Concepts Methods Application Effectiveness Efficiency Criteria for good care Improvement activities Big Patients Providers Organization Technology Information Costs Risks Innovation 41
42 Infrastructural Needs Assessment of actual situation: Structural analysis Rapid need assessment SWOT analysis Programme evaluation Part of certification 42
43 Essentials A Policy Document for Quality Assurance A Blue Print for Quality Assurance 43
44 Quality Assurance Policy Document Directed to Quality Assurance,not to quality Based on National Needs for Improvement of health services Items:definitions,principles,locus,focus,actors, costs,strategies 44
45 Contd….. Size:less than 32 pages Production Time: less than 9 months Easy to understand,no jargon Support by main parties(participants) Distributed widely Updated once in five years 45
46 Listing the Infrastructure The Body The Engine The Petrol Assembly line and Maintenance The Route Map The Driver And then ……On the road! 46
47 The Engine Policies Planning Mechanisms Implementation strategies Organization Resources Knowledge,skills,attitudes Value systems 47
48 The Body The system for quality assurance Information systems Conformity between healthcare system and QA system 48
49 The Driver Roles and Functions Education and Training License Rewards Remuneration Accountability Value Systems 49
50 The Petrol Epidemiology of Health and disease Epidemiology of quality(ABNA) Willingness to evaluate/be evaluated Willingness to Change and Improve Legislation Value Systems 50
51 Epidemiology of Quality Rumours and Hearsay Surveys:Opinions,Dissatisfaction Registration of Facts:Incidents Registration of Facts: Trends ABNA:Achievable Benefit Not Achieved 51
52 Maintenance Support mechanisms Research and Development Internal Quality Assurance System Value Systems 52
53 Assembling Quality Assurance A Laboratory (be in control) Real Life situations(hope the best) Value Systems Whatever you do, you still need a Manual and a Road Map! 53
54 Decision Making in Healthcare Improvement 54
55 Key Concerns: To find the decision makers: Who decides about quality? Who decides about quality improvement? To identify the client in health care quality improvement 55
56 Roles and Functions in Decision making in Quality Improvement The Consumers The Professionals The Managers The Government,Policy Makers 56
57 The Seven Roles of the Consumer Definers of Quality Evaluators of Quality Informants of Care Co-producers of care Targets of Quality Assurance Controllers of Practitioner Behavior Reformers of Health Services 57
58 The Seven Roles of the Provider To be accountable To provide quality care(plan,implement) To safeguard the quality of care services To be evaluated by colleagues To evaluate his colleagues To continue learning To collaborate with colleagues and management 58
59 Seven Roles and Functions of Management Do their job(Quality Management) Exert leadership Participate in Quality Management Communicate on Quality matters Be accountable re: quality Evaluation of Quality Management Provide resources 59
60 Role of Government Still open: Active role with responsibilities Support role with limited responsibilities No role at all 60
61 AUDIT Key Tool for QA Implementation 61
62 History of Audit Global Development: Until 1980s : the only mechanism available since 1985: superseded by CQI Since 1995: rebirth of audit as tool for professionals in CQI programmes Historical definition: audit is retrospective review of medical care as laid down in the medical record 62
63 Audit: a modern definition Is a criterion –referenced review of health care delivery to establish quality followed by, if necessary, specific activities to improve care delivery The method is used by professionals to assess and, if needed, improve the quality of their work 63
64 Audit :Applied with little more discipline Practical Solutions: Focusing on relevant health care delivery Focusing on multidisciplinary professional work Retrospective and concurrent in orientation Focus on assessment and improvement Based on reliable and valid data Not more time consuming than others 64
65 Audits’ Building Stones A well selected topic A limited number of relevant criteria Well selected reliable and valid data A functioning judgment procedure A will to change when needed Relevant changes leading to improvements 65
66 What are benefits in health care? Improvement in health status Increase in satisfaction Elimination of impairment Elimination of disability Elimination of risks Elimination of malfunctioning all due to present health care 66
67 What is ABNA? ABNA Maximum conceivable benefit Achievable benefit Benefit not achievable Achievable benefit achieved Achievable benefit not achieved Errors of commission Errors of omission 67
68 Well –chosen priorities Priorities for Quality Improvement: Are formulated in a clear mode Identify targets with high ABNA Identify all players in the field including patients Provide insight into attainable improvements Put the responsibility for quality improvement where it should be 68
69 Conclusion We should: Focus on generalities,later on specifics! Focus on gaps and weaknesses! Each country gets the quality assurance system it deserves! 69
71 Health Promotion as a Quality issue 11th International Conference on Health Promoting Hospitals Firenze May 18 – 20, 2003 71
72 Health promotion: “The process of enabling people to increase control over, and to improve, their health” (Ottawa Charter). Health education, disease prevention rehabilitation services. health enhancement by empowering patients, relatives and employees in the improvement of their health-related physical, mental and social well-being. 72
73 Quality assurance is a systematic process through Which achievable and desireable levels of quality are described,the extent to which these levels are achieved is assessed,and action is taken to enable them to be reached. This definition implies the need to set standards, to develop tools to audit their achievement and to engage in organizational and/or professional development where performance falls short of the standard expected." R Parish in: ” Evaluation in health promotion.Principles and Perspectives”. WHO Regional Publications,European Series No. 92, 2001, 171-184 73
74 Standards for Health Promotion in Hospitals Standard. The quality target, which should be achieved or maintained for a given activity within a limited time frame, i.e. the realistic target. 74
75 Perspectives.Standards for Health Promotion. I: A common set of standards can: Provide a framework for health promotion initiatives Give hospitals a platform for the planning of HP For documentation and evaluation of HP Support implementation of activities Be part of the hospitals' quality management. 75
76 Perspectives.Standards for Health Promotion II: A common set of standards can: Support learning internally in the organization Provide a platform for comparisons Uncover needs for disease prevention and health promotion Support co-operation between sectors Support the training of staff 76
77 Development of Standards: Alpha Programme Critical review of litterature Critical review of litterature Proposal for standards Proposal for standards Review Preliminary standards Preliminary standards ” Final standards” Implementation Revision and adjustment Revision and adjustment Pilot testing 77
78 Standards for Health Promotion in Hospitals The standards relate to the patient’s pathway. The standards define health promotion responsibilities activities integration in the hospitals services. 78
79 HPH – Patients´ Pathway Patients´ pathway Hospital Primary Health Care Sector Primary Health Care Sector Primary Health Care Sector Primary Health Care Sector 79
80 A Model for Quality Assessment in Hospitals Diagnostics Treatment Rehabilitation Health promotion Admission Assessment and plan Evaluation of clinical efforts Discharge Clinical perspective Care 80
81 A Model for Quality Assesment in Hospitals Information/ communication CoordinationContinuity Patients’ rights Safety Patients´ perspective 81
82 A Model for Quality Assesment in Hospitals Organisation and Structure 82
83 Standards for Health Promotion in Hospitals Standard 1: Management Policy Standard 2: Patient Assessment Standard 3: Patient Information and Intervention Standard 4: Promoting a Healthy Workplace Standard 5: Continuity and Cooperation 83
84 Standards for Health Promotion in Hospitals Standard 1. Management Policy The organization has a written policy for health promotion. The policy is implemented as part of the overall organization quality improvement system, aiming at improving health outcomes. This policy is aimed at patients, relatives and staff. Objective: The objective of this standard is to describe the framework for the organization's activities concerning health promotion as an integral part of the organization’s quality management system. 84
85 Standards for Health Promotion in Hospitals Standard 2. Patient Assessment The organization ensures that health professionals, in partnership with patients, systematically assess needs for health promotion activities. Objective: The objective of this standard is to support patient treatment, improve prognosis and to promote the health and well being of patients. 85
86 Standards for Health Promotion in Hospitals Standard 3. Patient Information and Intervention The organization provides patients with information on significant factors concerning their disease or health Condition and health promotion interventions are established in all patient pathways. Objective: The objective of this standard is to ensure that the patient is informed about planned activities, to empower the patient in an active partnership in planned activities and to facilitate integration of health promotion activities in all patient pathways. 86
87 Standards for Health Promotion in Hospitals Standard 4. Promoting a healthy Workplace The management establishes conditions for the development of the hospital as a healthy workplace. Objective: The objective of this standard is to support the establishment of a healthy and safe workplace for staff, and to support health promotion activities. 87
88 Standards for Health Promotion in Hospitals Standard 5.Continuity and Cooperation The organization has a planned approach to collaboration with other health service sectors and other institutions on an ongoing basis. Objective: The purpose of this standard is to ensure collaboration with relevant partners and to initiate networks in order to optimise the integration of health promotion activities in patient pathways 88
89 Standards for Health Promotion in Hospitals Next step : Translate standards to national languages Disseminate standards to: Health Promoting Hospitals Other Hospitals Accreditation Organizations Develop tool for self assessment Benchmarking National? International? Accreditation? 89
90 Standards for Health Promotion in Hospitals Conclusions: Standards have been developed in a proces involving National networks across HPH Standards are Relevant and Applicable Standards can be a strong tool in the implementation of Health Promotion in Hospitals 90
91 Standards for Health Promotion in Hospitals Acknowledgements The standards for health promotion in hospitals would not have materialized without the strong commitment of the authors and contributors, who agreed to develop many drafts to fit the overall aim. Specially thanks are due to the core Standards Working Group members, all the National and Regional Health Promoting Hospitals Coordinators, and experts in the field of health promotion and standards development. 91